Glenda Longoria

Craniospinal Project
Fall 2016

Craniospinal Irradiation Project

1. Describe the fields you use.
a. Superior, inferior and lateral borders
Cranial Field Borders1
Anterior

Entire cranium should be included with fall off

Superior

Fall off to include superior cranium

Posterior

Fall off to include posterior cranium

Inferior

Include temporal fossa, cribriform plate; posterior should extend to

the level of C2 at minimum to ensure adequate coverage of shifting
fields

Lateral

Occipital, parietal, and temporal bones

Glenda Longoria
Craniospinal Project
Fall 2016

Superior Spine Field Borders

Superior

Junction of inferior border of brain fields

Inferior

T10

Lateral

Include all vertebral bodies with at least 1.0 cm margin

Inferior Spine Field Borders

Superior

Junction of inferior border of superior spine field at level of

anterior spinal cord

Inferior

Below S2

Lateral

Include all vertebral bodies with at least 1 cm margin

Glenda Longoria
Craniospinal Project
Fall 2016

Because the spine field is separated into two separate fields, the field edges must be
separated to avoid radiation overlap in underlying tissues.2 Overlap doses can be
verified in the treatment planning software by entering the field information and
checking the isodose curves and/or point doses in the gap region. Daily OBI imaging
should also be acquired to verify correct field alignment, or portal images using wires
that mark the borders of the fields can also check for overlap.
b. Blocking: What is being blocked and why??
Part of the orbits have been blocked, as well as the mandible and surrounding normal
structures around the vertebral column. The radiation oncologist stated that it is
customary to treat part of the orbit as to not miss any of the brain tissue in the cranial
ports, and since there are no critical structures directly in the spinal fields, it was not
necessary to block any structures there except to keep the margins as close to 1 cm
around the vertebral bodies.
2. SAD or SSD?

Glenda Longoria
Craniospinal Project
Fall 2016

With the guidance and direction from my clinical preceptor and radiation oncologist, I was
able to create an SAD plan for this assignment. The dosimetrist had previous experience
with this type of set up before, making it easier for both of us to work on together.
3. Were calculation points placed? If so where and why? Did you plan to a volume or a
point? Is the plan normalized?
All calculation points were set at isocenter, which were centrally located for the brain and
spinal ports, with the depth for the spinal fields being near the spinal cord. The plans were
calculated to each of the calculation points, which helped pull the dose in the direction we
needed for an optimal plan. If placed too deep in the body, the plan was too hot, so bringing
it up closer to the spinal cord benefitted us by making it less hot and allowing for good
coverage. The plans were not normalized, instead we used the field in field technique to
eliminate hot spots from each of the treatment volumes.
4. In depth description of planning process?
To start, the data set that was used was the supine data set because this is how our physician
typically likes to treat the CSI patients at our facility and this is what our dosimetrist has
been accustomed to planning with.
The treatment planning process for this type of set up was time consuming due to the field
matching technique that we used. Several different plans were tested until we finally
achieved the one that we thought was best. The spine fields were set with gantry,
collimator, and table set at 0, leaving us with a diverging spine field that entered the whole
brain fields. To avoid this, I turned the collimator and the couch for both lateral brain fields
and left a small skin gap between the superior border of the superior spine field and the
inferior border of the brain fields. We also had to create a gap between the two spinal ports
to avoid a hot spot in the spinal cord. The divergence for these two fields had to be adjusted
so that the divergence occurred anterior to the spinal cord, avoiding a dangerous hotspot
for the patient. It was also important for me to remember to keep the isocenter in the same
lateral position for all fields, making it easier in treatment and in planning.

Glenda Longoria
Craniospinal Project
Fall 2016

Once our field sizes were set with the necessary gantry, collimator, and table rotations, we
were able to place our calculation points in the treatment areas, set the prescription, and
calculate the volumes. Initially, each of the treatment areas came back with an excess of
115% - 125% radiation dose, so we used the field in field technique to reduce the hot spots
for this plan, resulting in 106%, 105%, and 109% maximum doses for the brain, superior,
and inferior spine plans respectively. All plans had adequate coverage of the target
volumes by the 95% line.
The three plans were planned separately in our Eclipse system and once they were all
finished, we put them into a plan summary which compiled all three plans into one. It was
only here that I could see exactly how the hot spots and cold spots affected the plan,
allowing for a comprehensive analysis of the plan.
a. Screen shots and short descriptions of target volume and margins used
The target volume for the spine fields was the spinal cord itself, while the target volume
for the whole brain was also the whole brain. There were no GTVs, so planning was
based on the whole organs. The field borders were set by the standard CSI protocol
used by the radiation oncologist at my facility.

Glenda Longoria
Craniospinal Project
Fall 2016

b. Show isodose coverage of the volumes

Red = 148%
Pink = 131%
Blue = 119%
White = 110%
Cyan = 105%
Yellow = 100%
Green = 95%
Black = 90%
Dark Blue = 80%
Magenta = 70%
Brown = 50%

c. Hot or cold spots? Where are they located and why? If not, how did you prevent this?
In this plan there are two hot spots and one cold spot. The hot spots are located near
the junction of the spine and cranial ports, as well as at the point of intersection from
the spine fields. Both are a result of overlapping of the fields at a point in the patients
anatomy, however we were able to reduce the superior hot spot by leaving a small skin
surface gap between the cranial and spine fields, resulting in a hot spot that was fairly
small in comparison to the rest of the plan and does not include the spinal cord. The
hot spot located in the abdomen from the overlap reached a dose of 5558.4 cGy, a great
deal more than the prescribed dose, however it is not located in any of the OAR, it is a
very small area, and can be negligible considering the type of outcome we hope to
achieve. With this type of set up that I created for this project, it is necessary to shift
the fields every few fractions in order to keep the hot and cold spots to a minimum.
While talking to the radiation oncologist at our facility, he stated that he likes to shift
the fields every five fractions, which would make the hot and cold spots that we have
in this plan more reasonable. The location of the cold spot was a direct result of the
skin gap in the neck; however, I was able to get at least 80% coverage of the volume.

Glenda Longoria
Craniospinal Project
Fall 2016

Hot Spot - Abdomen

Red = 148%
Pink = 131%
Blue = 119%
White = 110%
Cyan = 105%
Yellow = 100%
Green = 95%
Black = 90%
Dark Blue = 80%
Magenta = 70%
Brown = 50%

Hot Spot - Neck

Red = 148%
Pink = 131%
Blue = 119%
White = 110%
Cyan = 105%
Yellow = 100%
Green = 95%
Black = 90%
Dark Blue = 80%
Magenta = 70%
Brown = 50%

Glenda Longoria
Craniospinal Project
Fall 2016

Cold Spot - Neck

Red = 148%
Pink = 131%
Blue = 119%
White = 110%
Cyan = 105%
Yellow = 100%
Green = 95%
Black = 90%
Dark Blue = 80%
Magenta = 70%
Brown = 50%

d. Identify the maximum dose location and tell if you were satisfied with its location
The maximum dose, as mentioned earlier is located in the patients abdomen. I am
satisfied with this location because it avoids the critical surrounding structures and
under normal circumstances in our center, this hot spot would not be as high as it is for
this plan because of shifting gaps between fractions.
e. Clearly label all of the isodose levels you evaluated and give a detailed summary of
your evaluation
You can see in the images above that the 95% isodose line completely encompasses all
of the fields and my hot and cold spots are clearly visible as well. With the shifting
field method that my physician recommends the dose would look more uniform. My

Glenda Longoria
Craniospinal Project
Fall 2016

overall opinion on this plan is that it is a treatable and viable option for our center. This
is the type of set up that our physician likes and what hes used to, however I really am
interested in seeing the newer techniques that do not require shifts between fractions.
They seem to offer the same, if not better, dose coverage without the difficulties of
shifting fields.
5. For all organs at risk contoured, tell what their tolerance doses are and whether these
tolerances were met or not.

Organ at
Risk
Kidney L
Kidney R
Lung Whole
Organ
Mandible
Heart
Liver
Optic Nerve L
Optic Nerve R
Optic Chiasm
Orbit L
Orbit R
Lens L
Lens R
Spinal Cord

Tolerance
Dose

Dose
Received

Tolerance
Met?

Mean less than 15 18 Gy

Mean less than 15 18 Gy
V20 less than 30%

Mean 328 cGy

Yes

Mean 328 cGy

Yes

Mean 909 cGy

Yes

V20 less than 30%

60 Gy
40 Gy
Mean less than 18
Gy
Dmax < 55 Gy
Dmax < 55 Gy
Dmax < 55 Gy
40 Gy
40 Gy
10 Gy
10 Gy
Dmax 50 Gy

Mean 909 cGy

3720 cGy
Mean 2250 cGy
Mean 967 cGy

Yes
Yes
Yes
Yes

3731 cGy
3714 cGy
3723 cGy
3649 cGy
3682 cGy
434 cGy
590 cGy
3971 cGy Dmax

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

Glenda Longoria
Craniospinal Project
Fall 2016
6. Provide a DVH with the CTV/PTV and all surrounding critical structures.

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Glenda Longoria
Craniospinal Project
Fall 2016

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References:
1. Vann AM, Dasher BG, Chestnut SK, et al. Portal Design in Radiation Therapy.
2nd ed. The R.L. Bryan Company. Columbia, SC. 2006.
2. Bentel G C. Radiation Therapy Planning. 2nd ed. New York, NY: McGraw-Hill;
1996.